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LEVELS OF CONSCIOUSNESS IN COMATOSE PATIENTS
422 the past
beginning at 28 weeks’ gestation or later, with 49 survivors out of 65 (75%). 7 of the 16 who died were hydropic at the time of referral, and many would have survived with earlier I.U.T. Although there is no strong evidence of the efficacy of plasmapheresis combined with LU.T., the moderate lowering of anti-D levels, at great cost in time and effort, may well be of marginal benefit in allowing initial I.U.T. to be delayed briefly. Once i.u.T. is begun and the fetus is depending upon donor Rhnegative red cells for his survival, no further benefit can be expected. The authors have proved that plasmapheresis alone has no place in the management of severe Rh disease. are
ten
years,
comparable,
with aminophylline produced a similar restoration of response to salbutamol. These results in normal subjects on treatment withadrenergic agonists are very similar to those described by EllulMicallef and Fenech in their asthmatic patients. The response in the asthamatic patients is greater, as expected, since the capacity for broncholilation is obviously limited in normal subjects. Our results suggest that the pharmacological interaction that they describe may not be specific to asthma.
treatment
Department of Medicine, Southampton Western Hospital, Southampton SO9 4WQ.
A. E. TATTERSFIELD S. T. HOLGATE
Rh Laboratory, Winnipeg, Manitoba, Canada.
JOHN
M. BOWMAN
LEVELS OF CONSCIOUSNESS IN COMATOSE PATIENTS
FAMILY PLANNING IN HOSPITALS
SIR,-It is really so simple. Professor Huntingford and his teaching-hospital colleagues (Feb. 7, p. 300) who object to payment for family-planning procedures only have to remember not to claim and no fee will be paid. But I hope that they are not seeking to prevent those who do not accept their argument from claiming these fees which were freely negotiated with the D.H.S.S. As one who has done many vasectomies within the N.H.S. during the past 8 years I find the Department’s action astonishing, unless it was intended to disrupt the profession. But because of other mean actions (e.g., their way of applying the payfreeze to part-timers’ salaries) I feel perfectly justified in taking a little smooth with the rough on this occasion. North Ormesby Hospital,
Middlesbrough, Cleveland TS3 6HJ.
ROGER HOLE
SIR,- The level of consciousness of a comatose patient is measured by the response to auditory and tactile stimuli,’ but such a scheme does not always relate to the ability of a patient to maintain an airway. Two signs described recently may be combined to form a new system: one, a measure of conscious awareness, involves alternately dorsiflexing and plantarflexing the foot with the heel kept in contact with the mattress; the other, a measure of awareness and vital airway obstruction, involves light pressure applied to the chin to obstruct the airway.3 The patient may be graded as follows:
(1) On moving the foot the head does not rock, or the patient reacts to the movement. At this level the patient controls his airway. (2) On moving the foot the head rocks and there is no sign of awareness of the movement, and on depressing the jaw the patient resists the threat to the airway. The patient’s airway is secure, but the lateral position is safer if vomiting occurs.
There is no reaction to moving the jaw but firm presdoes not obstruct the airway. Respiration is safe but the lateral position is essential if vomiting occurs. (4) Firm pressure on the chin obstructs respiration, but after a few seconds increasing inspiratory efforts open the airway. A pharyngeal airway is required; an orotracheal tube is safer if vomiting occurs or gastric lavage is performed. (5) As (4) but the increasing inspiratory efforts do not overcome the obstruction. A well-fitting oropharyngeal airway is essential. The use of an endotracheal tube should be considered.
(3)
sure
INTRAVENOUS PREDNISOLONE IN ASTHMA
SIR,-We read with interest the observations of Ellul-Micallef and Fenech’ on the effect of intravenous prednisolone on the isoprenaline response in a group of asthmatic patients who were previously refractory to catecholamines. Since most patients with mild or moderate asthma have a good response to p-adrenergic agonists the reasons for the poor response they obtained are interesting. Diminished response to p-adrenergic agonists has been ascribed to overuse of adrenergic aerosols:Z-4 but unfortunately Ellul-Micallef and French do not state what dose of p-agonists their patients had been taking previously nor when the treatment had been stopped. This may be important since we find that resistance to p-adrenergic agonists can be induced in normal subjects after prolonged treatment with large doses of inhaled &bgr;-agonists, and in this situation we demonstrated a similar interaction with hydrocortisone. Specific airway conductance (S. Gaw) in normal non-atopic subjects was measured in the body plethysmograph and plotted in a dose-response curve against inhaled salbutamol (25-400 Lg). After several baseline runs the subjects took large doses (up to 400 I-’-g four times/day) of inhaled salbutamol for 4-5 wk. The dose-response curves to salbutamol were repeated at the end of each week and showed a progressive reduction in the response to salbutamol. The maximum values of S. Gaw achieved at the end of each run were progressively less than those achieved during control runs. Preliminary results in a few subjects, when refractory to salbutamol, showed that intravenous hydrocortisone (200 mg) 2 h before testing restored the salbutamol dose-response curve to normal. Pre1. Ellul-Micallef, R., Fenech, F. F. Lancet, 1975, ii, 1269. 2. Van Metre, T. E. J. Allergy, 1969, 43, 101. 3. Reisman, R. E. ibid. 1970, 46, 162. 4. Conolly, M. E., Davies, D. S., Dollery, C. T., George, C. F.
1971, 43, 389.
Br. J.
Pharmac.
Observation of patients recovering from anaesthesia, drug overdose, and head injury confirm that the table forms a patof recovery from coma. The system cannot always be correlated with other schemes, which form unreliable criteria for assessing capacity for retaining patent airways, and it measures the capacity of the patient to maintain respiratory function rather than function itself. If respiration is obstructed and if the inspiratory movements do not immediately increase, the jaw should not be depressed for more than ten seconds, or for as long as the operator can hold a maximum expiration with comfort. In these cases endotracheal intubation is essential and oxygen should be admimstered cautiously since the respiratory centre may not be sensitive to increasing carbon-dioxide concentrations. tern
Department of Anæsthesia, North Tees General Hospital, Hardwick, Stockton-on-Tees, Cleveland TS19 8PE.
E.N.S.FRY
1. Matthews, H., Lawson, A. A. H. Treatment of Common Acute Poisons;p. 18. Edinburgh, 1975. 2. Fry, E. N. S. Br. med. J. 1974, ii, 505. 3. Grogono, A. W., Deacock, A. R. de C. ibid. 1974, ii, 174.
beginning at 28 weeks’ gestation or later, with 49 survivors out of 65 (75%). 7 of the 16 who died were hydropic at the time of referral, and many would have survived with earlier I.U.T. Although there is no strong evidence of the efficacy of plasmapheresis combined with LU.T., the moderate lowering of anti-D levels, at great cost in time and effort, may well be of marginal benefit in allowing initial I.U.T. to be delayed briefly. Once i.u.T. is begun and the fetus is depending upon donor Rhnegative red cells for his survival, no further benefit can be expected. The authors have proved that plasmapheresis alone has no place in the management of severe Rh disease. are
ten
years,
comparable,
with aminophylline produced a similar restoration of response to salbutamol. These results in normal subjects on treatment withadrenergic agonists are very similar to those described by EllulMicallef and Fenech in their asthmatic patients. The response in the asthamatic patients is greater, as expected, since the capacity for broncholilation is obviously limited in normal subjects. Our results suggest that the pharmacological interaction that they describe may not be specific to asthma.
treatment
Department of Medicine, Southampton Western Hospital, Southampton SO9 4WQ.
A. E. TATTERSFIELD S. T. HOLGATE
Rh Laboratory, Winnipeg, Manitoba, Canada.
JOHN
M. BOWMAN
LEVELS OF CONSCIOUSNESS IN COMATOSE PATIENTS
FAMILY PLANNING IN HOSPITALS
SIR,-It is really so simple. Professor Huntingford and his teaching-hospital colleagues (Feb. 7, p. 300) who object to payment for family-planning procedures only have to remember not to claim and no fee will be paid. But I hope that they are not seeking to prevent those who do not accept their argument from claiming these fees which were freely negotiated with the D.H.S.S. As one who has done many vasectomies within the N.H.S. during the past 8 years I find the Department’s action astonishing, unless it was intended to disrupt the profession. But because of other mean actions (e.g., their way of applying the payfreeze to part-timers’ salaries) I feel perfectly justified in taking a little smooth with the rough on this occasion. North Ormesby Hospital,
Middlesbrough, Cleveland TS3 6HJ.
ROGER HOLE
SIR,- The level of consciousness of a comatose patient is measured by the response to auditory and tactile stimuli,’ but such a scheme does not always relate to the ability of a patient to maintain an airway. Two signs described recently may be combined to form a new system: one, a measure of conscious awareness, involves alternately dorsiflexing and plantarflexing the foot with the heel kept in contact with the mattress; the other, a measure of awareness and vital airway obstruction, involves light pressure applied to the chin to obstruct the airway.3 The patient may be graded as follows:
(1) On moving the foot the head does not rock, or the patient reacts to the movement. At this level the patient controls his airway. (2) On moving the foot the head rocks and there is no sign of awareness of the movement, and on depressing the jaw the patient resists the threat to the airway. The patient’s airway is secure, but the lateral position is safer if vomiting occurs.
There is no reaction to moving the jaw but firm presdoes not obstruct the airway. Respiration is safe but the lateral position is essential if vomiting occurs. (4) Firm pressure on the chin obstructs respiration, but after a few seconds increasing inspiratory efforts open the airway. A pharyngeal airway is required; an orotracheal tube is safer if vomiting occurs or gastric lavage is performed. (5) As (4) but the increasing inspiratory efforts do not overcome the obstruction. A well-fitting oropharyngeal airway is essential. The use of an endotracheal tube should be considered.
(3)
sure
INTRAVENOUS PREDNISOLONE IN ASTHMA
SIR,-We read with interest the observations of Ellul-Micallef and Fenech’ on the effect of intravenous prednisolone on the isoprenaline response in a group of asthmatic patients who were previously refractory to catecholamines. Since most patients with mild or moderate asthma have a good response to p-adrenergic agonists the reasons for the poor response they obtained are interesting. Diminished response to p-adrenergic agonists has been ascribed to overuse of adrenergic aerosols:Z-4 but unfortunately Ellul-Micallef and French do not state what dose of p-agonists their patients had been taking previously nor when the treatment had been stopped. This may be important since we find that resistance to p-adrenergic agonists can be induced in normal subjects after prolonged treatment with large doses of inhaled &bgr;-agonists, and in this situation we demonstrated a similar interaction with hydrocortisone. Specific airway conductance (S. Gaw) in normal non-atopic subjects was measured in the body plethysmograph and plotted in a dose-response curve against inhaled salbutamol (25-400 Lg). After several baseline runs the subjects took large doses (up to 400 I-’-g four times/day) of inhaled salbutamol for 4-5 wk. The dose-response curves to salbutamol were repeated at the end of each week and showed a progressive reduction in the response to salbutamol. The maximum values of S. Gaw achieved at the end of each run were progressively less than those achieved during control runs. Preliminary results in a few subjects, when refractory to salbutamol, showed that intravenous hydrocortisone (200 mg) 2 h before testing restored the salbutamol dose-response curve to normal. Pre1. Ellul-Micallef, R., Fenech, F. F. Lancet, 1975, ii, 1269. 2. Van Metre, T. E. J. Allergy, 1969, 43, 101. 3. Reisman, R. E. ibid. 1970, 46, 162. 4. Conolly, M. E., Davies, D. S., Dollery, C. T., George, C. F.
1971, 43, 389.
Br. J.
Pharmac.
Observation of patients recovering from anaesthesia, drug overdose, and head injury confirm that the table forms a patof recovery from coma. The system cannot always be correlated with other schemes, which form unreliable criteria for assessing capacity for retaining patent airways, and it measures the capacity of the patient to maintain respiratory function rather than function itself. If respiration is obstructed and if the inspiratory movements do not immediately increase, the jaw should not be depressed for more than ten seconds, or for as long as the operator can hold a maximum expiration with comfort. In these cases endotracheal intubation is essential and oxygen should be admimstered cautiously since the respiratory centre may not be sensitive to increasing carbon-dioxide concentrations. tern
Department of Anæsthesia, North Tees General Hospital, Hardwick, Stockton-on-Tees, Cleveland TS19 8PE.
E.N.S.FRY
1. Matthews, H., Lawson, A. A. H. Treatment of Common Acute Poisons;p. 18. Edinburgh, 1975. 2. Fry, E. N. S. Br. med. J. 1974, ii, 505. 3. Grogono, A. W., Deacock, A. R. de C. ibid. 1974, ii, 174.